Stable isotope chemistry reveals plant-dominant diet among early foragers on the Andean Altiplano, 9.0-6.5 cal. ka

Current models of early human subsistence economies suggest a focus on large mammal hunting. To evaluate this hypothesis, we examine human bone stable isotope chemistry of 24 individuals from the early Holocene sites of Wilamaya Patjxa (9.0-8.7 cal. ka) and Soro Mik'aya Patjxa (8.0-6.5 cal. ka) located at 3800 meters above sea level on the Andean Altiplano, Peru. Contrary to expectation, Bayesian mixing models based on the isotope chemistry reveal that plants dominated the diet, comprising 70-95% of the average diet. Paleoethnobotanical data further show that tubers may have been the most prominent subsistence resource. These findings update our understanding of earliest forager economies and the pathway to agricultural economies in the Andean highlands. The findings furthermore suggest that the initial subsistence economies of early human populations adapting to new landscapes may have been more plant oriented than current models suggest.

The genetic prehistory of the Andean highlands 7000 years BP though European contact

The peopling of the Andean highlands above 2500 m in elevation was a complex process that included cultural, biological, and genetic adaptations. Here, we present a time series of ancient whole genomes from the Andes of Peru, dating back to 7000 calendar years before the present (BP), and compare them to 42 new genome-wide genetic variation datasets from both highland and lowland populations. We infer three significant features: a split between low- and high-elevation populations that occurred between 9200 and 8200 BP; a population collapse after European contact that is significantly more severe in South American lowlanders than in highland populations; and evidence for positive selection at genetic loci related to starch digestion and plausibly pathogen resistance after European contact. We do not find selective sweep signals related to known components of the human hypoxia response, which may suggest more complex modes of genetic adaptation to high altitude.

Book Review: What Teeth Reveal About Human Evolution

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Humans permanently occupied the Andean highlands by at least 7 ka

High-elevation environments above 2500 metres above sea level (m.a.s.l.) were among the planet's last frontiers of human colonization. Research on the speed and tempo of this colonization process is active and holds implications for understanding rates of genetic, physiological and cultural adaptation in our species. Permanent occupation of high-elevation environments in the Andes Mountains of South America tentatively began with hunter-gatherers around 9 ka according to current archaeological estimates, though the timing is currently debated. Recent observations on the archaeological site of Soro Mik'aya Patjxa (8.0-6.5 ka), located at 3800 m.a.s.l. in the Andean Altiplano, offer an opportunity to independently test hypotheses for early permanent use of the region. This study observes low oxygen (δ¹⁸O) and high carbon (δ¹³C) isotope values in human bone, long travel distances to low-elevation zones, variable age and sex structure in the human population and an absence of non-local lithic materials. These independent lines of evidence converge to support a model of permanent occupation of high elevations and refute logistical and seasonal use models. The results constitute the strongest empirical support to date for permanent human occupation of the Andean highlands by hunter-gatherers before 7 ka.

Rare combination of ipsilateral acetabular fracture-dislocation and pertrochanteric fracture

Acetabular fracture-dislocations are severe injuries that require urgent closed reduction of the hip and often require surgery to restore hip stability. Other authors have described acetabular fracture-dislocations associated with femoral neck fractures, but to our knowledge, this case report is the first to describe an acetabular fracture-dislocation in association with an ipsilateral pertrochanteric fracture and subtrochanteric extension. The polytraumatized patient initially was not stable enough for prolonged surgery. Through a 3-cm anterolateral hip incision, a 5-mm Schanz screw was introduced percutaneously into the femoral head through the primary fracture site under fluoroscopic guidance. With inline traction on the leg, the Schanz screw was used to manipulate the femoral head back into the acetabular fossa. The Schanz screw was removed, the head remained reduced, and a skeletal traction pin was placed to maintain length and alignment of the pertrochanteric fracture until definitive stabilization was possible. We propose a staged treatment strategy consisting of early closed reduction of the hip, and after the patient has been stabilized, reduction and fixation of the fractures. This strategy may be useful in managing an unstable polytraumatized patient or a patient who requires prolonged transfer to receive definitive care.

Introduction of agriculture and its effects on women's oral health

This study explores the dynamic relationship between the introduction of agriculture and its effects on women's oral health by testing the hypothesis that female reproductive physiology contributes to an oral environment more susceptible to chronic oral disease and that, in a population undergoing the foraging to farming transition, females will exhibit a higher prevalence of oral pathology than males. This is tested by comparing the presence, location, and severity of caries lesions and antemortem tooth loss across groups of reproductive aged and postreproductive females (n = 71) against corresponding groups of males (n = 71) in an Early Agricultural period (1600 B.C.-A.D. 200) skeletal sample from northwest Mexico. Caries rates did not differ by sex across age groups in the sample; however, females were found to exhibit significantly more antemortem tooth loss than males (P > 0.01). Differences were initially minimal but increased by age cohort until postreproductive females experienced a considerable amount of tooth loss, during a life stage when the accumulation of bodily insults likely contributed to dental exfoliation. Higher caries rates in females are often cited as the result of gender differences and dietary disparities in agricultural communities. In an early farming community, with diets being relatively equal, women were found to experience similar caries expression but greater tooth loss. We believe this differential pattern of oral pathology provides new evidence in support of the interpretation that women's oral health is impacted by effects relating to reproductive biology.

Methicillin-resistant Staphylococcus aureus infections among healthy full-term newborns

OBJECTIVE

Methicillin-resistant Staphylococcus aureus (MRSA) strains have emerged in the community, causing disease among healthy people lacking traditional risk factors for MRSA infection. This article describes an outbreak of MRSA among healthy full-term newborns.

DESIGN

Cases were identified and corresponding medical information collected. Telephone interviews were conducted with mothers of cases and surveillance cultures from mothers and newborns were performed. MRSA isolates were genotyped.

SETTING

Hospital in Chicago, Illinois, USA.

PARTICIPANTS

Newborns, their mothers and hospital healthcare workers.

INTERVENTION

Nursery infection control practices were enhanced. The MRSA-colonised healthcare workers received intranasal mupirocin.

MAIN OUTCOME

Within 4-23 days of birth, 11 newborns were identified with pustules, vesicles or blisters located on the head, groin, perineum, ears, legs, chin and trunk. All received antimicrobials and recovered without incident.

RESULTS

None of 432 peripartum women, one of 399 newborns, and two of 135 healthcare workers were nasal MRSA carriers. Available isolates from six patients, two healthcare workers, and one from an MRSA-colonised newborn were similar by pulsed-field gel electrophoresis. Other than contact with the hospital, no common exposures of MRSA transmission were identified.

CONCLUSIONS

MRSA strains that initially emerged in the community are now causing disease in healthcare settings. Providers should be aware that MRSA can cause skin infections among healthy newborns. Adherence to standard infection control practices is important to prevent transmission of MRSA in nurseries.

Exploring the thrifty genotype's food-shortage assumptions: a cross-cultural comparison of ethnographic accounts of food security among foraging and agricultural societies

The "thrifty genotype hypothesis" has become firmly entrenched as one of the orienting concepts in biomedical anthropology, since first being proposed by Neel (1962 Am. J. Hum. Genet. 14:353-362) over 40 years ago. Its influence on inquiries into the evolutionary origins of diabetes, lactose tolerance, and other metabolic disorders can hardly be underestimated, as evidenced by its continued citation in many top scientific and medical journals. However, its fundamental assumption, that foragers are more likely to experience regular and severe food shortages than sedentary agriculturalists, remains largely untested. The present report tests this assumption by making a cross-cultural statistical comparison of the quantity of available food and the frequency and extent of food shortages among 94 foraging and agricultural societies as reported in the ethnographic record. Our results indicate that there is no statistical difference (P < 0.05) in the quantity of available food, or the frequency or extent of food shortages in these reports between preindustrial foragers, recent foragers, and agriculturalists. The findings presented here add to a growing literature that calls into question assumptions about forager food insecurity and nutritional status in general, and ultimately, the very foundation of the thrifty genotype hypothesis: the presumed food shortages that selected for a "thrifty" metabolism in past foraging populations.

Control of climbing behavior in the cockroach, Blaberus discoidalis. II. Motor activities associated with joint movement

Deathhead cockroaches employ characteristic postural strategies for surmounting barriers. These include rotation of middle legs to re-direct leg extension and drive the animal upward. However, during climbing the excursions of the joints that play major roles in leg extension are not significantly altered from those seen during running movements. To determine if the motor activity associated with these actions is also unchanged, we examined the electromyogram activity produced by the slow trochanteral extensor and slow tibial extensor motor neurons as deathhead cockroaches climbed over obstacles of two different heights. As they climbed, activity in the slow trochanteral extensor produced a lower extension velocity of the coxal-trochanteral joint than the same frequency of slow trochanteral extensor activity produces during horizontal running. Moreover, the pattern of activity within specific leg cycles was altered. During running, the slow trochanteral extensor generates a high-frequency burst prior to foot set-down. This activity declines through the remainder of the stance phase. During climbing, motor neuron frequency no longer decreased after foot set-down, suggesting that reflex adjustments were made. This conclusion was further supported by the observation that front leg amputees generated even stronger slow trochanteral extensor activity in the middle leg during climbing movements.

Control of obstacle climbing in the cockroach, Blaberus discoidalis. I. Kinematics

An advantage of legged locomotion is the ability to climb over obstacles. We studied deathhead cockroaches as they climbed over plastic blocks in order to characterize the leg movements associated with climbing. Movements were recorded as animals surmounted 5.5-mm or 11-mm obstacles. The smaller obstacles were scaled with little change in running movements. The higher obstacles required altered gaits, leg positions and body posture. The most frequent sequence used was to first tilt the front of the body upward in a rearing stage, and then elevate the center of mass to the level of the top of the block. A horizontal running posture was re-assumed in a leveling-off stage. The action of the middle legs was redirected by rotations of the leg at the thoracal-coxal and the trochanteral-femoral joints. The subsequent extension movements of the coxal-trochanteral and femoral-tibial joints were within the range seen during horizontal running. The structure of proximal leg joints allows for flexibility in leg use by generating subtle, but effective changes in the direction of leg movement. This architecture, along with the resulting re-direction of movements, provides a range of strategies for both animals and walking machines.

Capture and identification of folding intermediates of cystinyl proteins by cyanylation and mass spectrometry

Trapping folding intermediates of cystinyl proteins by covalent modification of free sulfhydryl groups provides the opportunity for isolation, purification, and structural elucidation of individual species. The disulfide structure of the intermediates, coupled with their temporal abundance, provides a 'snapshot' of the pathway experienced by the refolding protein in a particular medium. Here, intermediates of cystinyl proteins containing free cysteines are trapped by cyanylation through reaction with an acidic (pH 3.0) solution of 1-cyano-4-dimethylamino-pyridinium (CDAP) tetrafluoroborate. The cyanylated species are separated by reversed-phase high-performance liquid chromatography, where the resulting chromatogram gives a visual indication of the distribution of intermediates at a designated time after commencing the refolding process. The disulfide structure of an intermediate can be determined by cleaving its cyanylated derivative and by mass mapping of the resulting fragments to the sequence of the original protein. Cleavage of a cyanylated species represented by any given peak in the chromatogram is achieved by treatment of that fraction with 1M NH4OH at room temperature for 1 h; the resulting fragments are analyzed by matrix-assisted laser desorption ionization (MALDI) or electrospray mass spectrometry. Examples will be presented from in vitro refolding experiments with human epidermal growth factor (hEGF), for which more than 10 folding intermediates were isolated and identified at different time points, and a mutant of insulin-like growth factor-I, for which three intermediates were isolated and identified.

Epinephrine reduces the sedative side effects of epidural sufentanil for labour analgesia

PURPOSE

The use of opioids in labour analgesia has primarily been as an adjuvant to local anesthetics. For early labour, satisfactory analgesia with epidural sufentanil alone is possible. This study evaluates the impact of epinephrine on sedative side effects and analgesia related to the latter technique.

METHODS

After Institutional Review Board approval and informed consent this prospective, randomized, double-blind study evaluated 43 nulliparous subjects requesting epidural analgesia. The study site, a tertiary care obstetric unit, accommodates 3500-4500 deliveries annually. Group selection was randomized and blinded by selection of a sealed envelope containing a number which corresponded to a premixed labelled syringe of saline or epinephrine (100 microg/mL). An epidural catheter was placed in a standardized fashion. All subjects received 40 microg of sufentanil and 0.5 mL from the premixed syringe, diluted to 10 mL with NaCl. A blinded observer collected data on maternal sedation, lightheadedness, hemodynamics, oxygenation, and fetal heart rate over a one-hour period following sufentanil injection.

RESULTS

The addition of epinephrine significantly (P <0.05) reduced the incidence of sedation and lightheadedness after epidural sufentanil at all data collection points, except two. Analgesic duration was also significantly prolonged by this addition (120 +/- 56 vs 84 +/- 32 min). Maternal satisfaction was high regardless of solution.

CONCLUSION

Forty micrograms of epidural sufentanil produces satisfactory analgesia in early labour. The addition of epinephrine improves the side effect profile of this technique while prolonging the duration of analgesia. Epidural sufentanil requires attention to maternal monitoring of oxygenation as maternal desaturation occurred in both groups.

Long-term use of a left ventricular assist device for end-stage heart failure

BACKGROUND

Implantable left ventricular assist devices have benefited patients with end-stage heart failure as a bridge to cardiac transplantation, but their long-term use for the purpose of enhancing survival and the quality of life has not been evaluated.

METHODS

We randomly assigned 129 patients with end-stage heart failure who were ineligible for cardiac transplantation to receive a left ventricular assist device (68 patients) or optimal medical management (61). All patients had symptoms of New York Heart Association class IV heart failure.

RESULTS

Kaplan-Meier survival analysis showed a reduction of 48 percent in the risk of death from any cause in the group that received left ventricular assist devices as compared with the medical-therapy group (relative risk, 0.52; 95 percent confidence interval, 0.34 to 0.78; P=0.001). The rates of survival at one year were 52 percent in the device group and 25 percent in the medical-therapy group (P=0.002), and the rates at two years were 23 percent and 8 percent (P=0.09), respectively. The frequency of serious adverse events in the device group was 2.35 (95 percent confidence interval, 1.86 to 2.95) times that in the medical-therapy group, with a predominance of infection, bleeding, and malfunction of the device. The quality of life was significantly improved at one year in the device group.

CONCLUSIONS

The use of a left ventricular assist device in patients with advanced heart failure resulted in a clinically meaningful survival benefit and an improved quality of life. A left ventricular assist device is an acceptable alternative therapy in selected patients who are not candidates for cardiac transplantation.

Quantitative variation in vascular endothelial growth factor mRNA expression during early flexor tendon healing: an investigation in a canine model

Vascular endothelial growth factor (VEGF) is a potent mediator of angiogenesis, with direct mitogenic activity on cells of endothelial origin. We quantified the temporal accumulation of VEGF mRNA at the repair site of an in vivo canine intrasynovial flexor tendon repair and rehabilitation model by means of quantitative Northern blot analysis, in order to detail a molecular signal involved in the intrinsic angiogenic process that accompanies early flexor tendon healing. Significant accumulation of VEGF mRNA occurred at the flexor tendon repair site at 7 days post-operatively, with peak levels seen at post-operative days 7 and 10. Levels returned to baseline by day 14. Local VEGF mRNA accumulation at the repair site temporally precedes and is spatially distinct from the vascular ingrowth itself, which has been shown to occur maximally at day 17. These data suggest that cells within the flexor tendon repair site are involved in molecular processes other than the synthesis of extracellular matrix, such as modulation of angiogenesis.

Determination of the disulfide structure of sillucin, a highly knotted, cysteine-rich peptide, by cyanylation/cleavage mass mapping

The disulfide structure of sillucin, a highly knotted, cysteine-rich, antimicrobial peptide, isolated from Rhizomucor pusillus, has been determined to be Cys2--Cys7, Cys12--Cys24, Cys13--Cys30, and Cys14--Cys21 by disulfide mass mapping based on partial reduction and CN-induced cleavage enabled by cyanylation. The denatured 30-residue peptide was subjected to partial reduction by tris(2-carboxyethyl)phosphine hydrochloride at pH 3 to produce a mixture of partially reduced sillucin species; the nascent sulfhydryl groups were immediately cyanylated by 1-cyano-4-(dimethylamino)pyridinium tetrafluoroborate. The cyanylated species, separated and collected during reversed phase high-performance liquid chromatography, were treated with aqueous ammonia, which cleaved the peptide chain on the N-terminal side of cyanylated cysteine residues. The CN-induced cleavage mixture was analyzed by matrix-assisted laser desorption ionization time-of-flight mass spectrometry before and after complete reduction of residual disulfide bonds in partially reduced and cyanylated species to mass map the truncated peptides to the sequence. Because the masses of the CN-induced cleavage fragments of both singly and doubly reduced and cyanylated sillucin are related to the linkages of the disulfide bonds in the original molecule, the presence of certain truncated peptide(s) can be used to positively identify the linkage of a specific disulfide bond or exclude the presence of other possible linkages.

Mass spectrometric evidence for mechanisms of fragmentation of charge-derivatized peptides

Mass spectrometry of charged derivatives of peptides has been a growing area of interest in the past decade. Fragmentation of charged derivatives of peptides is believed to be different from than that of protonated peptides when analyzed by collisionally activated dissociation-tandem mass spectrometry (CAD-MS/MS). The charged derivatives fragment by charge-remote fragmentation mechanisms, which are usually classified as high-energy (HE)-CAD processes. Our objective in the present study is to investigate the mechanism of fragmentation of charged derivatives of peptides when analyzed by matrix-assisted laser desorption/ionization-postsource decay-mass spectrometry (MALDI-PSD-MS) and electrospray ionization (ESI)-CAD-MS/MS (ion trap), which involve low-energy processes. Three major types of hydrogens (alpha, beta, and amide) are available for migration during the formation of the *a(n) ions (the predominant ion series produced from these charged derivatives). To pinpoint which of the three hydrogens is involved in the formation of the *a(n) ions, deuterium-labeled peptide derivatives with labels at specific sites were synthesized and analyzed by MALDI-PSD-MS and ESI-CAD-MS/MS. Our results suggest that the amide hydrogen of the residue at which the cleavage occurs shifts during the formation of *a(n); this observation serves as evidence for the mechanism proposed earlier by Liao et al. for fragmentation of such charged derivatives. The results also help elucidate the structure of the *a(n) ions, *b(n) ions, and others formed during cleavage at the proline residue, as well as the ions formed during loss of the C-terminal residue from these charged derivatives.

The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multicenter trial

In a prospective, nonrandomized, multicenter study, 109 patients with bone defects were treated with a surgical grade calcium sulfate preparation as a bone graft substitute. The calcium sulfate pellets were used in place of morselized cancellous bone graft for the treatment of patients with bone defects who usually would require grafting secondary to trauma, periprosthetic bone loss, tumor, or fusion. The calcium sulfate was used alone or mixed with other materials such as bone marrow aspirate, demineralized bone matrix, or autograft. The defects that were treated were contained and were not necessary for the stability of the bony structure. Radiographic and clinical data were collected at predetermined intervals for 12 months. At 6 months postoperatively, radiographic results for all patients showed that 99% of the calcium sulfate had been resorbed and 88% of the defect was filled with trabeculated bone. There were 13 complications; however, only four (3.6%) were attributable to the product. The results of a subgroup of 46 patients with benign bone lesions treated in the same manner are identical to the results of the overall study population. Surgical grade calcium sulfate pellets are considered a convenient, safe, and readily available bone graft substitute that yield consistent successful results.

Open reduction and internal fixation of posterior wall fractures of the acetabulum

The results of 94 patients with posterior wall fractures of the acetabulum associated with hip instability treated within 3 weeks of injury by open reduction and internal fixation were reviewed. Patients were followed up for an average of 3.5 years (range, 1-13 years). Fracture reductions were graded as anatomic (0-1 mm displacement) in 92 patients and imperfect (2-3 mm displacement) in two patients, as determined by plain radiography. However, postoperative computed tomography scans obtained in 59 patients revealed incongruency of more than 2 mm in six patients and fracture gaps of 2 mm or more in 44 patients. Complications included deep wound infection (one patient), deep vein thrombosis, (seven patients), and revision surgery to redirect an errant screw (one patient). Clinical outcome was graded as excellent in 34 patients (36%), good in 49 (52%), fair in two (2%), and poor in nine (10%). Radiographic results were excellent in 79 hips (84%), good in four (4%), fair in two (2%), and poor in nine (10%). There was a strong association between clinical outcome and radiographic grade. Variables identified as risk factors for an unsatisfactory result included age greater than 55 years, a delay greater than 24 hours from the time of injury for reduction of a hip dislocation, a residual fracture gap greater than 1 cm, and severe intraarticular comminution. The apparent disparity between the accuracy of surgical fracture reduction, as determined by plain radiographs obtained postoperatively, and clinical outcome is explained only partially by the limitations of plain radiography. Other variables are involved, many of which are under the surgeon's control but some are not. As is the case with other acetabular fracture types, the best results are predicated on anatomic fracture reduction.

Pilon fractures. Treatment protocol based on severity of soft tissue injury

One hundred seven pilon fractures in 107 patients were treated according to a staged prospective protocol. All pilon fractures were stabilized immediately by the application of calcaneal traction. Open fractures or fractures in patients with multiple injuries were stabilized with traveling traction that was applied in the operating room. A distraction computed tomography scan was obtained before definitive treatment. Treatment groups were based on the degree of soft tissue compromise. Forty-one patients with Tscherne Grade 0 or Grade I injuries underwent open reduction and internal fixation (open plating) using contemporary techniques and low-profile implants. Sixty-four patients with Tscherne Grade II and Grade III closed injuries and all patients with open fractures underwent definitive treatment with limited open reduction and stabilization using small wire circular external fixators. Clinical and radiographic evaluations were performed at an average 4.9 years after injury. For all fracture types (AO classification), 81% of the patients who were treated with external fixation and 75% of the patients who were treated with open plating had good or excellent results. For severe fracture patterns (Type C), patients in both groups had significantly poorer results than patients with Types A and B fractures. The patients in the open plating group had a significantly higher rate of nonunion, malunion, and severe wound complications compared with the patients who received external fixation for Type C fracture patterns. Because of the increased incidence of bony and soft tissue complications when treating open or closed Type C fractures, use of limited exposures and stabilization with small wire circular external fixators is recommended.

Investigation of the tris(trimethoxyphenyl)phosphonium acetyl charged derivatives of peptides by electrospray ionization mass spectrometry and tandem mass spectrometry

Charged derivatives of peptides are useful in obtaining simpler collision-activated dissociation (CAD) mass spectra. An N-terminal charge-derivatizing reagent capable of reacting with picomole levels of peptide has been recently reported (Huang et al. Anal. Chem. 1997, 69, 137-144) in the contexts of analyses by fast atom bombardment (FAB) and matrix-assisted laser desorption/ionization (MALDI) mass spectrometry. Electrospray ionization (ESI) mass spectrometric investigation of these tris(trimethoxyphenylphosphonium) acetyl derivatives are described in this article, including studies by in-source fragmentation (ISF) and tandem mass spectrometry (MS/MS). Results from ISF are compared with those from MS/MS. Similarities and differences between ESI-ISF, MALDI-post-source decay (PSD), and FAB-CAD data are presented. Differences in fragmentation of these charged derivatives in the triple quadrupole and ion trap mass spectrometers also are discussed. Application of this derivatizing procedure to tryptic digests and subsequent analysis by liquid chromatography-mass spectrometry is also shown.

Probing the folding pathways of long R(3) insulin-like growth factor-I (LR(3)IGF-I) and IGF-I via capture and identification of disulfide intermediates by cyanylation methodology and mass spectrometry

This report describes an integrated investigation of the refolding and reductive unfolding of insulin-like growth factor (IGF-I) and its variant, long R(3) IGF-I (LR(3)IGF-I), which has a Glu(3) to Arg(3) substitution and a hydrophobic 13-amino acid N-terminal extension. The refolding performed in glutathione redox buffer was quenched at different time points by adjusting the pH to 2.0-3.0 with a 1 N HCl solution of 1-cyano-4-dimethylaminopyridinium tetrafluoroborate, which trapped intermediates via cyanylation of free sulfhydryl groups. The disulfide structure of the intermediates was determined by chemical cleavage followed by mass mapping with mass spectrometry. Six refolding intermediates of IGF-I and three refolding intermediates of LR(3)IGF-I were isolated and characterized. Folding pathways of IGF-I and LR(3)IGF-I are proposed based on the time-dependent distribution and disulfide structure of the corresponding trapped intermediates. Similarities and differences in the refolding behavior of IGF-I and LR(3)IGF-I are discussed.

Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty

We prospectively studied the continuous "modified" femoral three-in-one block for postoperative pain after total knee arthroplasty. Sixty-two patients undergoing elective knee arthroplasty under spinal anesthesia with bupivacaine (B) and fentanyl were randomized to receive 0.2% B, 0.1% B, or placebo at 10 mL/h for 48 h after an initial bolus of 30 mL of the same solution via the femoral block catheter. The catheters were inserted under the fascia iliaca using a "double pop" technique and a peripheral nerve stimulator and were advanced 15-20 cm cranially. Venous plasma levels of B, desbutylbupivacaine, and 4-hydroxy B were measured daily for 3 days. All patients received patient-controlled analgesia with morphine and indomethacin suppositories for 48 h. Using computed tomography, we evaluated the catheter location for 20 patients. The catheter tips, located superior to the upper third of the sacroiliac joint in the psoas sheath, were labeled as ideally located. The group receiving 0.2% B had a larger block success rate, smaller morphine consumption in the immediate postoperative period (15 vs 22 mg) and during the first postoperative day (9 vs 18 mg), and achieved a greater range of motion in the immediate postoperative period (91 degrees +/- 10 degrees vs 80 degrees + 13 degrees ). Visual analog scores for pain during both rest and activity were low but similar between the groups. Forty percent of the catheters evaluated were ideally located. Ideal location and use of 0.2% B resulted in 100% success of blockade of all three nerves. The S1 root was blocked in up to 76% of patients. The plasma levels of B, 4-hydroxy B, and desbutylbupivacaine were below the toxic range during the infusion. We conclude that continuous fascia iliaca block with 0.2% B results in opioid-sparing and improved range of motion during the immediate postoperative period. Larger doses of bupivacaine may safely be used in the immediate postoperative period if needed.

IMPLICATIONS

Continuous fascia iliaca block with 0.2% bupivacaine reduces opioid requirements and improves range of motion in the immediate postoperative period compared with a placebo and 0.1% bupivacaine. Plasma levels are below the toxic range with this dose. Only 40% of the catheters are positioned in the ideal location. With the smaller dose of bupivacaine, the success rate with this block is small.

Retrograde nailing of the femoral shaft

Retrograde intramedullary nailing of fractures of the femoral shaft with use of a distal intercondylar intra-articular entry portal is a relatively new surgical technique. This method of nailing represents a modification of the previously described procedure in which an extra-articular entry portal in the medial femoral condyle was used. The earlier procedure was plagued by technical difficulties, which limited its use; these problems were mainly related to the fact that the entry portal was not in line with the intramedullary canal, as well as to the fact that purpose-specific implants and instrumentation were not available. Modification of this technique, by using the intercondylar entry portal and a nail designed for retrograde insertion, has proved very effective in clinical studies. There have been theoretical concerns regarding postoperative knee function and intraoperative injury to important anatomic structures, such as branches of the femoral nerve; however, laboratory and clinical findings have dispelled many of these concerns and have provided firm support for continued use of the technique. Nonetheless, further study is required to delineate the long-term outcome of knee joint function. Current indications for use of this technique include multisystem injuries, multiple fractures (including ipsilateral lower-limb combination injuries), ipsilateral vascular injuries, periprosthetic fractures, and morbid obesity.

Protein sequencing by matrix-assisted laser desorption ionization-postsource decay-mass spectrometry analysis of the N-Tris(2,4,6-trimethoxyphenyl)phosphine-acetylated tryptic digests

We have recently reported a simple procedure by which low picomole quantities of peptides can be modified to the corresponding N-Tris(2, 4,6-trimethoxyphenyl)phosphonium-acetyl (TMPP-Ac) derivatives (Z. H Huang, J. Wu, D. A. Gage, and J. T. Watson, Anal. Chem. 69, 137-144, 1997). This modification significantly facilitates sequence interpretation by providing exclusively N-terminal product ions (mainly a-type ions) in the fast-atom bombardment-MS/MS and matrix-assisted laser desorption ionization-postsource decay(MALDI-PSD)-MS spectra. The TMPP-Ac derivatization approach has been extended now for the direct derivatization of tryptic digests originating from 1-5 microg of proteins with molecular weights from 10-120 kDa. Our new procedure involves tryptic digestion in aqueous solution buffered to pH 8-8.2 with phosphate or Tris-HCl, followed by reaction with TMPP-acetic acid N-hydroxysuccinimide ester (TMPP-AcOSu bromide, 2-4 nmol reagent/microg protein, rt, 20 min) to provide N-terminally derivatized products, while the epsilon-NH2 groups in lysine remain unchanged. The resultant derivatized peptide mixture or its partially separated HPLC fractions are subsequently analyzed by MALDI-PSD-MS using 0.5- to 1-pmol aliquots, giving rise to product ion spectra that are easily interpretable. As there is no need for material transfer and change of buffer media, the tandem enzymatic-chemical reaction/MS analysis process is usually carried out with very high throughput (digestion, 1 h; reaction, 1/3 h; HPLC, 1 h; MALDI-PSD, 3-4 fragments/h). This procedure will be of potential use for obtaining sequence information directly from mixtures or as an adjunct of peptide mass mapping to provide protein identification with high confidence.

The REMATCH trial: rationale, design, and end points. Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure

BACKGROUND

Because left ventricular assist devices have recently been approved by the Food and Drug Administration to support the circulation of patients with end-stage heart failure awaiting cardiac transplantation, these devices are increasingly being considered as a potential alternative to biologic cardiac replacement. The Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) trial is a multicenter study supported by the National Heart, Lung, and Blood Institute to compare long-term implantation of left ventricular assist devices with optimal medical management for patients with end-stage heart failure who require, but do not qualify to receive cardiac transplantation.

METHODS

We discuss the rationale for conducting REMATCH, the obstacles to designing this and other randomized surgical trials, the lessons learned in conducting the multicenter pilot study, and the features of the REMATCH study design (objectives, target population, treatments, end points, analysis, and trial organization).

CONCLUSIONS

We consider what will be learned from REMATCH, expectations for expanding the use of left ventricular assist devices, and future directions for assessing clinical procedures.

Long-term mechanical circulatory support system reliability recommendation: American Society for Artificial Internal Organs and The Society of Thoracic Surgeons: long-term mechanical circulatory support system reliability recommendation

Jointly developed by members of the American Society for Artificial Internal Organs and the Society of Thoracic Surgeons along with staff from the Food and Drug Administration, the National Heart, Lung and Blood Institute and other experts, this recommendation describes the reliability considerations and goals for Investigational Device Exemption and Premarket Approval submissions for long-term, mechanical circulatory support systems. The recommendation includes a definition of system failure, a discussion of an appropriate reliability model, a suggested in vitro reliability test plan, reliability considerations for animal implantation tests, in vitro and animal in vivo performance goals, the qualification of design changes during the Investigational Device Exemption clinical trial, the development of a Failure Modes Effects and Criticality Analysis, and the reliability information for surgeons and patient candidates. The document will be periodically reviewed to assess its timeliness and appropriateness within five years.

Treatment of complex lateral plateau fractures using Ilizarov techniques

Fourteen high energy atypical Schatzker Types I and II fractures were treated using a combination of contemporary internal fixation techniques and Ilizarov methodologies. Fracture were atypical if the primary lateral condylar fracture line extended anteromedially with complete detachment of the tibial tubercle, or posteromedially with extension into the medial or posterior medial tibial condyle, both in association with comminution of the lateral condyle and impaction of the lateral articular surface. Preoperative traction computed tomography scans were used to direct incisions to the area of joint involvement. Fixation included hook plate stabilization of anterior tubercle fragments in five fractures. Adjunctive lateral, medial, or posterior antiglide plates were used where olive wire stabilization was contraindicated because of anatomic constraints. Fractures were neutralized by a three-ring Ilizarov external fixator. At followup, average 19.2 months (range, 8-67 months), all fractures had healed, and 85% had good or excellent knee scores (Knee Society clinical rating scale). Five patients had minor pin tract complications and one patient had a superficial wound slough. This combined approach has shown excellent results for this complex fracture pattern without the severe soft tissue complications associated with internal fixation techniques for high energy fractures.

Charge derivatization of peptides for analysis by mass spectrometry

The analysis of peptide derivatives by fast atom bombardment, liquid secondary-ionization mass spectrometry, plasma desorption, electrospray ionization, and matrix-assisted laser desorption/ionization is reviewed. The fragmentation patterns of peptides and of charge-derivatized peptides are compared, and the proposed fragment ion structures are summarized. A variety of derivatization approaches and the distinguishing features of mass spectra produced from these derivatives are described. The most promising derivatization approaches are evaluated, and the strengths and limitations of these approaches are discussed.

Unreamed retrograde intramedullary nailing of fractures of the femoral shaft

OBJECTIVE

To evaluate the efficacy of unreamed retrograde intramedullary (IM) nailing of fractures of the femoral shaft in a second series of patients using modifications suggested from our initial study.

DESIGN

Prospective.

SETTING

Level I trauma center.

METHODS

Based on the findings of a previous study, we began a clinical series incorporating changes consisting of (a) inclusion of any patient with a femoral shaft fracture amenable to IM nailing (i.e., closed physes), (b) primary use of a split patellar tendon intercondylar distal femoral entry portal, and (c) the use of a full-length femoral implant having variable size availability and dynamization capability. Over a twelve-month period, thirty-four patients with thirty-five femoral shaft fractures were treated. The protocol called for planned dynamization in statically locked stable fractures and unstable fractures showing minimal healing at six to twelve weeks. Functional outcome was assessed by using the Knee Society clinical rating system.

RESULTS

Incorporating the concepts of canal fill and early dynamization, there were only two nonunions (6 percent) in this series as compared with 14 percent in the previously reported series with an overall shorter time to union (12.6 versus 15 weeks). There were no infections or malunions. Postoperative complaints of knee pain were minimal (knee score average: 98 points) and knee function was excellent (knee score average: 97 points).

CONCLUSIONS

Although not advocated as a replacement for other techniques, unreamed retrograde nailing is presented as a safe and beneficial fracture fixation method that should be added to the orthopaedic surgeon's treatment armamentarium. The operative technique is quick and simple, and blood loss is minimal. Early nail dynamization and early weight-bearing are important in minimizing the risk of nonunion.

Optimization of the cleavage reaction for cyanylated cysteinyl proteins for efficient and simplified mass mapping

Peptide chains can be cleaved selectively on the N-terminal side of cysteine residues after cyanylation of sulfhydryl groups to form an amino-terminal peptide and a series of 2-iminothiazolidine-4-carboxyl peptides. This paper describes a systematic study that was carried out to elucidate the effects of peptide structure and reaction conditions on the kinetics of the reactions and the yields of cleavage products. Both cleavage and beta-elimination reactions under different conditions (pH 8.0, 9.0, and 12.0 and 1 M ammonia solution) were quantitatively evaluated using reversed-phase HPLC and matrix-assisted laser desorption/ionization-MS. Contrary to previous reports, our results showed that higher pH greatly accelerates both cleavage and beta-elimination reactions, while the relative yield of beta-elimination products does not increase for most of the peptides studied. Optimal results were obtained in 1 M ammonium hydroxide solution, in which cleavage is complete within an hour at ambient temperature. This improvement also minimizes side reactions otherwise associated with long hours of exposure to alkaline conditions, [original report called for 12 to 80 h of incubation in mildly alkaline (pH 8-9) buffer]. The yields of cleavage reactions depend primarily on the structure of amino acids on the N-terminal side of cyanylated cysteines; the Pro-Cys and Tyr-Cys bonds were resistant to cleavage, promoting beta-elimination as the main reaction. The improved cleavage conditions greatly simplify the analytical procedure, which has been successfully applied to the determination of cysteine status in spinach ferredoxin, ovalbumin, and rabbit muscle creatine phosphokinase.

Outcomes following repair of quadriceps tendon ruptures

OBJECTIVES

The purpose of this study was to examine critically the outcomes of patients sustaining a quadriceps tendon rupture and to compare outcomes in patients with bilateral simultaneous ruptures versus a unilateral rupture.

DESIGN

Retrospective review.

SETTING

Patients were treated at a Level I trauma center.

PATIENTS/PARTICIPANTS

Fifty-one quadriceps tendon ruptures in thirty-nine patients were evaluated. A mean four-year follow-up (range 13 to 204 months) was available for forty-eight tendon ruptures.

INTERVENTIONS

All patients except one were treated with operative repair of the quadriceps tendon rupture(s).

MAIN OUTCOME MEASUREMENTS

Patients were assessed by physical examination, Lysholm and Tegner scores, a functional questionnaire, quadriceps isokinetic testing, and radiographs.

RESULTS

A statistically greater number of patients in the bilateral simultaneous rupture group had a systemic illness associated with tendon rupture (p = 0.014). This result did not adversely affect outcome as compared with patients with unilateral ruptures. Mean range of motion was 123 degrees in injured knees. Eighty-four percent of working patients returned to their previous occupations. More than half the patients, however, in general the most active, could no longer participate in their preinjury recreational activities. Fifty-three percent of unilateral rupture patients had persistent quadriceps strength deficits (>20 percent) in the injured extremity. Both quadriceps and hamstring isokinetic testing correlated significantly with Lysholm and Tegner scores.

CONCLUSIONS

Most patients with bilateral simultaneous and unilateral tendon repairs can expect a good range of motion and return to their previous occupation, but many have persistent weakness and difficulty returning to higher level sporting activities.

Trapping of intermediates during the refolding of recombinant human epidermal growth factor (hEGF) by cyanylation, and subsequent structural elucidation by mass spectrometry

Human epidermal growth factor (hEGF) contains 53 amino acids and three disulfide bonds. The unfolded, reduced hEGF is allowed to refold under mildly alkaline conditions. The folding is quenched at different time points by adjusting the pH to 3.0 with an acetic acid solution of 1-cyano-4-dimethylamino-pyridinium (CDAP) which traps folding intermediates via cyanylation of free sulfhydryl groups. The mixture of cyanylated intermediates is separated by reversed-phase HPLC; the fractions collected are identified by mass spectrometry. The disulfide structures of the intermediates are then determined by specific chemical cleavage and mass-mapping by MALDI-MS, a novel approach developed in our laboratory. The procedure of quenching and trapping of disulfide intermediates in acidic solution minimizes sulfhydryl-disulfide exchange, and therefore provides a good measure of folding kinetics and preservation of intermediate species. Our cyanylation methodology for disulfide mapping is simpler, faster, and more sensitive than the more conventional approach. Among 18 folding intermediates isolated and identified at different time points, disulfide structures of seven well-populated intermediates, including two non-native isomers with scrambled disulfide structures, one 2-disulfide intermediate, and four 1-disulfide intermediates, have been characterized; most of them possess non-native disulfide structures.

Comparison of the compression hip screw with the Medoff sliding plate for intertrochanteric fractures

The Medoff sliding plate was designed to achieve compression along the femoral neck and the longitudinal axis of the femoral shaft theoretically to improve the treatment of intertrochanteric hip fractures. The Medoff sliding plate was compared with a standard compression hip screw in a randomized, prospective study for the fixation of 160 stable and unstable intertrochanteric fractures with an average followup of 9.5 months (range, 6-26 months). Overall, 91 fractures were treated using the compression hip screw and 69 were treated with the Medoff sliding plate. Stable fracture patterns (46) united without complication in both treatment groups. Unstable fractures (114) had an overall failure rate of 9.6%, 14% (nine patients) with the compression hip screw and 3% (two patients) with the Medoff plate; this difference was significantly different. The time to union for the 114 unstable fractures was not significantly different between the two devices. For all patients, no differences in lengths of hospitalization, return to ambulatory status before fracture, postoperative living status, or postoperative pain was observed between the two device groups. Use of the Medoff plate for all fracture types was associated with a significantly higher amount of blood loss and operating time.

Ultrasound for the early diagnosis of tibial fracture healing after static interlocked nailing without reaming: clinical results

OBJECTIVE

Based on the results of a pilot study indicating the potential value of ultrasound (US) as a diagnostic tool for the early assessment of fracture healing and the related need for secondary operative procedures in patients treated by statically locked intramedullary (IM) nailing without reaming, a protocol was established for a larger scale prospective trial. The purpose of this study was to evaluate the outcome of this follow-up trial.

DESIGN/METHODS

All skeletally mature patients admitted to the Henry Ford Hospital (Detroit, Michigan) from January 1993 to August 1994 who had sustained an acute fracture of the tibial shaft and who were treated by statically locked IM nailing, without reaming, were candidates for study. Forty-seven patients with fifty fractures that could be evaluated by US were included. The adopted determinants for fracture healing were complete disappearance of the IM nail on US examination performed at six weeks postoperatively, or progressive disappearance of the nail noted between the initial six-week study and a second nine-week US examination, both in conjunction with periosteal callus formation. Radiographs were obtained to monitor maintenance of reduction and to further evaluate fracture healing.

RESULTS

Of thirty-eight fractures with a positive US (thirty-two at six weeks, six at nine weeks), thirty-seven healed uneventfully, a positive predictive value of 97 percent. Radiographic fracture healing was not evident until, on average, nineteen weeks after injury. The single false-positive fracture progressed to nonunion. Of the twelve fractures with negative US studies, ten underwent secondary procedures (nine dynamization, one bone graft), with four progressing to nonunion. Two patients refused secondary surgery; screw failure occurred in both. Otherwise, there were no hardware failures in this series.

CONCLUSIONS

The results of this study indicate that US may provide important prognostic information concerning fracture healing after unreamed tibial nailing, upon which subsequent treatment can be based.

A historical perspective and commentary on pioneering developments in gas chromatography/mass spectrometry at MIT

Klaus Biemann has helped shape many aspects of the field of modern mass spectrometry. This paper reviews and comments on some of his innovative contributions to gas chromatography/mass spectrometry (GC/MS) during the 1960s and 1970s with particular emphasis on the molecular separator, a comprehensive plan for the acquisition and processing of GC/MS data and the application of GC/MS to the analysis of drugs in emergency cases.

Leg kinematics and muscle activity during treadmill running in the cockroach, Blaberus discoidalis: II. Fast running

We have combined kinematic and electromyogram (EMG) analysis of running Blaberus discoidalis to examine how middle and hind leg kinematics vary with running speed and how the fast depressor coxa (Df) and fast extensor tibia (FETi) motor neurons affect kinematic parameters. In the range 2.5-10 Hz, B. discoidalis increases step frequency by altering the joint velocity and by reducing the time required for the transition from flexion to extension. For both Df and FETi the timing of recruitment coincides with the maximal frequency seen for the respective slow motor neurons. Df is first recruited at the beginning of coxa-femur (CF) extension. FETi is recruited in the latter half of femur-tibia (FT) extension during stance. Single muscle potentials produced by these fast motor neurons do not have pronounced effects on joint angular velocity during running. The transition from CF flexion to extension was abbreviated in those cycles with a Df potential occurring during the transition. One effect of Df activity during running may be to phase shift the beginning of joint extension so that the transition is sharpened. FETi is associated with greater FT extension at higher running speeds and may be necessary to overcome high joint torques at extended FT joint angles.

Long-term mechanical circulatory support system reliability recommendation: American Society for Artificial Internal Organs and Society of Thoracic Surgeons: long-term mechanical circulatory support system reliability recommendation

Jointly developed by members of the American Society for Artificial Internal Organs and the Society of Thoracic Surgeons along with staff from the Food and Drug Administration, the National Heart, Lung and Blood Institute and other experts, this recommendation describes the reliability considerations and goals for Investigational Device Exemption and Premarket Approval submissions for long-term, mechanical circulatory support systems. The recommendation includes a definition of system failure, a discussion of an appropriate reliability model, a suggested in vitro reliability test plan, reliability considerations for animal implantation tests, in vitro and animal in vivo performance goals, the qualification of design changes during the Investigational Device Exemption clinical trial, the development of a Failure Modes Effects and Criticality Analysis, and the reliability information for surgeons and patient candidates. The document will be periodically reviewed to assess its timeliness and appropriateness within five years.

Leg kinematics and muscle activity during treadmill running in the cockroach, Blaberus discoidalis: I. Slow running

We have combined high-speed video motion analysis of leg movements with electromyogram (EMG) recordings from leg muscles in cockroaches running on a treadmill. The mesothoracic (T2) and metathoracic (T3) legs have different kinematics. While in each leg the coxa-femur (CF) joint moves in unison with the femurtibia (FT) joint, the relative joint excursions differ between T2 and T3 legs. In T3 legs, the two joints move through approximately the same excursion. In T2 legs, the FT joint moves through a narrower range of angles than the CF joint. In spite of these differences in motion, no differences between the T2 and T3 legs were seen in timing or qualitative patterns of depressor coxa and extensor tibia activity. The average firing frequencies of slow depressor coxa (Ds) and slow extensor tibia (SETi) motor neurons are directly proportional to the average angular velocity of their joints during stance. The average Ds and SETi firing frequency appears to be modulated on a cycle-by-cycle basis to control running speed and orientation. In contrast, while the frequency variations within Ds and SETi bursts were consistent across cycles, the variations within each burst did not parallel variations in the velocity of the relevant joints.